13- ANTIPHOSPHOLIPID SYNDROME

• Antiphospholipid syndrome (APS)


  A syndrome characterized by thrombosis and/or recurrent miscarriages and persistently positive blood tests for antiphospholipid antibodies
• Antiphospholipid antibodies


  • Anticardiolipin (more with spontaneous abortions)
  • Lupus anticoagulant (more with high APTT)
  • Anti-b2-glycoprotien
• Antiphospholipid antibodies


  • Thought to play role in thrombosis by reacting with plasma proteins and phospholipids with an effect on platelet membranes, endothelial cells and clotting compounds
• Major clinical features of APS


  • Stroke, TIA, MI (in arteries)
  • DVT, Budd-Chiari syndrome (in veins)
  • Recurrent miscarriages (in the placenta)
  • Valvular heart disease, migraine, epilepsy, thrombocytopenia, renal impairment, accelerated atheroma (others)
• Diagnosis of APS


  Based on a combination of clinical features and laboratory findings
• Criteria for APS diagnosis


  • Clinical criteria: Vascular thrombosis, Pregnancy morbidity
  • Lab criteria: Presence of one or more antiphospholipid antibodies (IgG and/or IgM anticardiolipin, IgG and/or IgM anti-beta2-glycoprotein, Lupus anticoagulant)
• Treatment of APS


  1. Asymptomatic APL antibody does not need treatment

  2. Acute thromboembolism: heparin overlapped with warfarin

  3. Duration of treatment controversial if single episode (6 months vs lifelong)

  4. Recurrent thrombotic episodes treated lifelong with long-term anticoagulation

  5. For secondary thrombosis prevention: warfarin better than NOAC (INR 2-3)

  6. If pregnant: LMWH instead of warfarin, +/- aspirin
• When to investigate spontaneous abortion for APL: ≥ 2 1st trimester events or Single 2nd trimester event